ISSN: 2574-1241 Volume 5- Issue 4: 2018

DOI: 10.26717/BJSTR.2018.08.001654
Ahmed Hossain. Biomed J Sci & Tech Res

Research Article Open Access

Socio-Demographic Risk Factors of Surgical Site

Infections in Inguinal Hernia Surgery: A Hospital-based
Case-Control Study in Dhaka
Maruf Hasan1,2, Abrar Wahab1, Mohammad Alam1 and Ahmed Hossain1*
1
Department of Public Health, North South University, Bangladesh
2
Kurmitola General Hospital, Bangladesh
Received: August 21, 2018; Published: August 28, 2018
*Corresponding author: Ahmed Hossain, Department of Public Health, North South University, Bangladesh

Abstract

Background: Surgical site infection (SSI) is the dominant cause of unplanned and potentially preventable hospital readmissions in surgical
patients. The main objective of this study is to determine the risk factors of SSI among patients undergoing inguinal hernia operation.

Materials and Methods: We conducted a hospital-based case control study from March 30, 2017, to November 29, 2017, on a total of 176
patients undergoing inguinal hernia operation in a public Hospital of Dhaka. We used a semi-structured questionnaire to collect data on patients’
characteristics and a checklist containing three questions to identify the SSI.

Results: The mean age of the study population was 42 years among case group and 44 years among the control group. The multivariate analysis
reflects the risk factors associated with SSI are age of above 35 years (OR= 3.84, CI=1.41-11.39), day-labor (OR= 3.032, CI = 1.23-7.79), employed
(OR = 3.650, CI= 1.16-8.46), and having diabetes more than 5 years (OR= 4.160, CI= 1.54-13.26). We also found 5.7% of cases showed Methicillin
Resistance Staphylococcus Aureus growth, and 58.0% of cases showed Methicillin non- Resistance Staphylococcus aureus growth.

Conclusion: The identified risk factors for the SSI reflect a complex interaction among socio-demographic conditions. Although further study is
warranted to validate these results, the socio-demographic factors presented may be a useful tool to stratify patient risk of SSI.

Keywords: Bangladesh; Surgical Site Infection; Inguinal Hernia Operation; Odds Ratio

Introduction
An inguinal hernia is a protrusion of abdominal cavity contents
through the inguinal canal. Usually an inguinal hernia gets worse
during the day and improves at night when lying down. Initially,
it produces severe pain and tenderness of the area [1]. Inguinal
hernias are the most common form of abdominal wall hernias, and
it is the most common surgical pathology [2]. The risk of getting
inguinal hernia repair is estimated to be 27% for men and 3% for
women [3]. About 500,000 cases come to medical attention each
year in the United States [2]. The incidence of the total annual need
for inguinal hernia repair in rural sub-Saharan Africa is estimated
to be a minimum of 205/100,000 population [4]. The inguinal
hernia operation causes SSI infection which may lead to a fatal
outcome [5]. Inguinal, femoral and abdominal hernias resulted in
51,000 deaths globally in 2013 [6]. Surgical site infection (SSI) is
the most common nosocomial infection among surgical patients
which accounts for 38% of postoperative complications [7]. It is the
dominant cause of unplanned and potentially preventable hospital
readmissions in surgical patients [8], which results in apparently
20,000 potentially avoidable deaths per year [9]. These infections
occur in an increase in morbidity, duration of hospital stay, health-
care expenses, and mortality [10-11].
In the United States alone, these complications translate
into additional health-care costs more than three billion dollars
per year [9]. In general, antibiotics are being used to treat most
SSI, but patients with SSI may need another surgery to treat
their infection [12]. The prevalence of occurring SSI in patients
undergoing surgery is 5%, which may cause much morbidity and
on a rare occasion, it can be fatal as well. Other patient-related
factors are; low serum albumin concentration, obesity, older age,
diabetes mellitus, ischemic heart disease, and smoking. Potential
risk factors also include prolonged procedures and inadequacies in
either the surgical scrub or the antiseptic preparation of the skin
[13]. Microorganisms on the patient’s skin and the alimentary tract
or female genital tract are the most common sources of infection
[13,14]. The most prevalent bacteria to be isolated is Staphylococcus
aureus, which often is found to be resistant to methicillin or

Biomedical Journal of
Scientific & Technical Research (BJSTR)
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Biomedical Journal of Scientific & Technical Research
other classes of antibiotics given at the time of operation [13]. As
laparoscopic surgeries are less common in inguinal hernia surgery
in Bangladesh, it is essential to identify the factors related to
open inguinal hernia repair surgery and to minimize them. So far,
nationally representative data on factors related to SSI on inguinal
hernia surgery are not available in Bangladesh. Therefore, the study
aimed to investigate the potential risk factors associated with SSI in
inguinal hernia surgery.
Methods
Data
The study was conducted from March 30, 2017, to November
29, 2017, in Kurmitola General Hospital which is a public hospital
located in the capital city of Dhaka. As of 2017, it has a bed capacity
of 500, and at present, it serves about 4000 outdoor, and 400
indoor patients daily. The study sample size was determined using
the difference in proportions formula. The assumptions used for
the sample size calculation are; desired power (80%), level of
statistical significance (1.96), the ratio of controls to cases (1:1),
the proportion of cases exposed (assumed 33%), and proportion of
controls exposed (assumed 20%). Therefore, the required sample
was 88 cases and 88 controls.
Inclusion Criteria
a) Cases were patients undergone inguinal hernia operation
and develop SSI within 6 weeks.
b) Controls were patients undergone inguinal hernia
operation but did not develop SSI within 6 weeks of their
operation.
c) Age: 18–64 years old.
Exclusion Criteria
a) Patient with more than one surgery including inguinal
hernia operation.
b) History of having other infectious diseases like AIDS, TB,
Syphilis, Hepatitis B, & Hepatitis C infection.
c) Patients with incomplete data or history sheet.
d) Those who were not willing to participate in the study.
Independent Variables
We used a structured questionnaire to collect information on
age, sex (male or female), occupation (unemployed, employed or
day-labor), duration of diabetes (No diabetes, < 5 years and >= 5
years), marital status, education, ischemic heart disease (yes or no),
and use of antibiotics within 3 months of the surgery (yes or no).
The use of antibiotics was measured by the question “Did you take
any antibiotics during the last three months before the surgery?”.
Measures of SSI
We performed a checklist for the identification of cases. That
checklist consisted of 3 questions, and those were “pain with
redness (+,-) at the surgical site,” “drainage of fluid from the wound”
and “fever.” For a positive response of each question gave 1 score
Cite this article: Maruf H, Abrar W, Mohammad A, Ahmed H. Socio-Demographic Risk Factors of Surgical Site Infections in Inguinal Hernia
Surgery: A Hospital-based Case-Control Study in Dhaka. Biomed Sci&Tech Res 8(3)- 2018. BJSTR MS.ID.001654.
DOI: 10.26717/ BJSTR.2018.08.001654.
Volume 8- Issue 3: 2018
and for negative response of each item gave 0 scores. With a total
score of 3, we have determined if the patient had SSI or not. If the
patients had SSI then, pus or the fluid was sent for an antimicrobial
resistance test.
Statistical Analysis
After collection of data, all interviewed questionnaires were
checked for completeness, correctness and internal consistency
to exclude missing or inconsistent data. Statistical analysis of the
data was conducted using R. Descriptive analysis was computed as
a percentage for categorical variables and means for continuous
variables. Unadjusted odds ratio, adjusted odds ratio, and their
95% confidence intervals [CIs] were used as indicators of the
strength of association. Multivariate analysis was carried out using
logistic regression to examine the relationship between dependent
variable and independent variables.
Results
About 88 cases and 88 controls consented to participate in the
study and fulfilled the eligibility criteria. The mean age of the study
population was 42 years among case group and 44 years among
the control group. Our descriptive analysis illustrated the ratio of
male and female in case group was 76.2% and 23.8% respectively,
and similarly, in control group, the ratio was 70.5% and 29.5%
(Table 1). It appears from the boxplot of age that the occurrence
of SSI is increasing as the increase of age. Our descriptive
analysis also showed, no bacterial growth was found for 36.4%
cases, 5.7% cases showed Methicillin Resistance Staphylococcus
Aureus growth, and lastly, 58.0% cases showed Methicillin non-
Resistance Staphylococcus aureus growth (Table 2). The patients’
characteristics and unadjusted analysis are presented in Table 2.
Among these covariates day labor (OR= 3.032, CI = 1.23-7.79),
employed (OR = 3.650, CI= 1.16-8.46), and duration of diabetes
(OR= 4.160, CI= 1.54-13.26) were found significantly associated
with the SSI according to the values of the unadjusted odds ratio.
It appears that patients with more than five years of diabetes are
at four times more risk of getting SSI compared to patients without
diabetes. A multivariate logistic regression model was fitted after
adjusting the extraneous variables, as presented in (Table 3). The
risk factors for SSI were found as Age and Occupation (employed).
It appears that participants older than 35 years old are 3.84
times more likely to have SSI while undergoing an inguinal hernia
operation than compared to the participants with the age of 35
years and less (OR= 3.84, CI=1.41-11.39). The study suggests that
participants who are employed are 4.54 times more likely to have
SSI compared to the participants who are unemployed (OR= 4.543,
CI= 1.78-12.30). Our study also suggests that male participants
are at 55% lesser risk of getting SSI during their inguinal hernia
operation compared to female participants (OR= 0.558, CI= 0.22-
1.31), though we have not found any statistical significance for
this result. From our multivariate analysis, we also observed the
use of antibiotics prior to the inguinal hernia operation acted as
a protective factor (OR= 0.364, CI= 0.14-0.87) which indicates the
patient who took antibiotics before the operation are approximately
60% less in risk of developing SSI.
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Table 1: Patient’s characteristics and unadjusted odds ratio of each covariates and case-control.
Case Controls
Factors Categories Odds Ratio (CI) P-Value
n = 88 (%) n = 88 (%)
Age < = 35 years 41 (46.5) 53 (60.2) 1
> 35 years 47 (53.5) 35 (39.8) 1.73 (0.95-3.17) 0.0707
Sex Female 21 (23.8) 26 (29.5) 1
Male 67 (76.2) 62 (70.5) 1.33 (0.68-2.63) 0.395
Occupation Unemployed 11 (12.5) 29 (33) 1
Day labour 23 (26.2) 20 (22.7) 3.03 (1.23-7.79) 0.01775
Employed 54 (61.3) 39 (44.3) 3.65 (1.66-8.46) 0.00166
Marital Status Married 66 (75) 65 (73.9) 1
Unmarried 22 (25) 23 (26.1) 0.94 (0.47-1.85) 0.863
Education Literate 70 (79.5) 63 (71.6) 1
Illiterate 18 (20.5) 25 (28.4) 0.64 (0.32-1.29) 0.221
Duration of Diabetes 0 50 (56.8) 52 (59.1) 1
< 5 years 18 (20.4) 31 (35.2) 0.60 (0.29-1.20) 0.15703
> 5 years 20 (22.8) 05 (5.7) 4.16 (1.54-13.26) 0.00803
Antibiotic use prior 3
No 61 (69.3) 53 (60.2) 1
months of operation
Yes 27 (30.7) 35 (39.8) 0.67 (0.35-1.24) 0.208

Table 2: Organism detected in culture and sensitivity test from the pus collected from the site of infection of the cases.
Organism Number Percentage
No growth 32 36.4%
Staphylococcus aureus (Methicillin Resistance) 5 5.7%
Staphylococcus aureus (Methicillin Non-Resistance) 51 58.0%
Total 88 100.0%
Table 3: Adjusted relationship between covariates and case-control that is analyzed by multivariate logistic regression model.
Factors Reference Estimate Odds Ratio LCL UCL P-value
Age (> 35 years) < = 35 years 1.347 3.847 1.412 11.399 0.01083
Sex (Male) Female -0.583 0.558 0.228 1.311 0.1885
Marital Status (Unmarried) Married 0.780 2.183 0.822 6.009 0.1219
Occupation(Day labour) Unemployed 0.578 1.783 0.566 5.761 0.3248
Occupation (Employed) Unemployed 1.513 4.543 1.789 12.302 0.00197
Antibiotic use prior 3 months of operation
No -1.009 0.364 0.140 0.878 0.02942
(Yes)

Note: LCL 95% lower confidence limit for OR UCL 95% upper confidence limit for OR.

Discussion
Our study showed that multiple factors are contributing to the
development of SSI after an inguinal hernia operation. This analysis
disclosed three independent risk factors for SSI: duration of
diabetes, age, and occupation. Our study posited that patients with
more than six months of diabetes were at more risk of developing
SSI. In a systematic review and meta-analysis considered diabetes as
an independent risk factor for SSI and diabetes patients undergoing
surgery were 50 percent more likely to develop an SSI [15]. There
are other studies which also found diabetes as a risk factor for the
development of SSI [16–18]. Older age is a known independent risk
factor for the development of SSI after inguinal hernia operation
[19,20]. Our study also illustrated that participants with the age of
more than 35 years old were more likely at risk of having SSI after
an inguinal hernia operation. In a recent retrospective, case-control
study found that the age of > 65 years old as an independent risk
factor and the rate of SSI increased for each decade of increasing
age [18].
There are not so many studies that explored the relationship of
occupation with SSI. However, there was a finding in a prospective
cohort study where it mentioned that wound care has possibilities
to be hampered among employed persons [21]. In our study
occupation was also found as another significant risk factors for SSI.
This result could be due to the fact that people who are day-labor
or employed, they remain in a rush to get back to their work just
right after their surgery without any prolonged rest and because

Cite this article: Maruf H, Abrar W, Mohammad A, Ahmed H. Socio-Demographic Risk Factors of Surgical Site Infections in Inguinal Hernia
Surgery: A Hospital-based Case-Control Study in Dhaka. Biomed Sci&Tech Res 8(3)- 2018. BJSTR MS.ID.001654. 6506
DOI: 10.26717/ BJSTR.2018.08.001654.
Biomedical Journal of Scientific & Technical Research
of this the wound care becomes affected which opens the door of
SSI among these people. Therefore, it is particularly important that
health care providers make their patients more cautious about
their wound care.
Limitations
This study finding should be interpreted in light of several
limitations. First, we conducted this study in a single hospital
with relatively smaller sample size. Second, few of the patients
had incomplete history sheet, and incomplete directory needed
extra afford for the fulfillment. Third, after analyzing our data, we
found that the variable of taking antibiotics three months prior to
their operation acted as a protective factor. So we would advise
researchers to exclude this type of patients from their future study.
Finally, the time for the study was comparatively limited. Thus, the
more illustrated research should be carried out in future including
various regions of the country and with more samples from broader
background and study should be done in depth.
Conclusion
This study suggests few socio-demographic factors that are
associated with the SSI among adults in Bangladesh. Our study
showed the history of diabetes and age of > 35 years old increases the
chance of developing SSI significantly. But the highlight of this study
is that over 60% of patients who were employed and day-labor had
SSI after the surgery, which indicates occupation as an important
factor in developing SSI. This probable risk factor has not been
explored in any research study till now. So our recommendation to
the health care providers and surgeons that this group of patients
should give attention with care while undergoing an operation.
Although further study is warranted to validate these results, the
identified socio-demographic factors may be a useful tool to stratify
patient risk of SSI.
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Cite this article: Maruf H, Abrar W, Mohammad A, Ahmed H. Socio-Demographic Risk Factors of Surgical Site Infections in Inguinal Hernia
Surgery: A Hospital-based Case-Control Study in Dhaka. Biomed Sci&Tech Res 8(3)- 2018. BJSTR MS.ID.001654.
DOI: 10.26717/ BJSTR.2018.08.001654.
Volume 8- Issue 3: 2018
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Cite this article: Maruf H, Abrar W, Mohammad A, Ahmed H. Socio-Demographic Risk Factors of Surgical Site Infections in Inguinal Hernia
Surgery: A Hospital-based Case-Control Study in Dhaka. Biomed Sci&Tech Res 8(3)- 2018. BJSTR MS.ID.001654. 6508
DOI: 10.26717/ BJSTR.2018.08.001654.